Integrating national evidence with global standards: China’s updated dengue and chikungunya diagnosis and treatment plans

Abstract

China released updated national plans for dengue (2024) and chikungunya (2025) to standardize clinical management amid expanding Aedes-borne risk, recurrent importations with episodic local amplification, and heterogeneous diagnostic capacity. This article synthesizes the clinical and operational content of these documents, situates them within China’s epidemiologic context, and appraises areas of alignment and nuance relative to World Health Organization (WHO) and Pan American Health Organization (PAHO) recommendations. The revised plans recalibrate case stratification and advise against routine corticosteroids/Immunoglobulin therapy(IVIG) for chikungunya. Infection prevention and discharge criteria are operationalized by coupling defervescence with time- and/or virologic-based thresholds. Compared with WHO and PAHO, China converges on core principles—supportive care, early recognition, and judicious fluids management—while adding pragmatic features for arbovirus-endemic settings, notably an explicit dual-testing trigger for febrile arthralgia (simultaneous dengue and chikungunya testing) and more prescriptive discharge and precaution language. Implementation rests on a hub-and-spoke diagnostic model: frontline nonstructural protein 1 antigen testing with reflex Nucleic Acid Amplification Test via prefecture or provincial CDC laboratories, supported by external quality assessments for dengue, chikungunya, and Zika. Domestic evidence strengthens the plans’ real-world clinical applicability: field epidemiology with genotyping demonstrates importation-seeded local transmission; hospital cohorts validate the use of warning-sign–guided escalation, window-based testing, and risk stratification for frail patients; and health-economic analyses inform preseason capacity planning. The remaining gaps are practical rather than conceptual, but they matter because they directly affect patient outcomes and system readiness: pathways for chronic chikungunya arthropathy, pediatric- and pregnancy-specific operational details, tier-appropriate diagnostic turnaround standards, and numeric thresholds linked to time-bound escalation. Overall, China’s 2024–2025 plans harmonize with international norms while translating them into implementable routines for mixed-transmission environments, offering a replicable model for regions facing overlapping arboviral threats.

1. Introduction

Arboviral diseases transmitted by Aedes mosquitoes—particularly dengue, chikungunya, and Zika—are expanding in geographic reach and clinical burden. In response, the WHO published an integrated clinical-management guideline that emphasizes syndromic overlap and harmonized care.^[1] China mirrors these trends but displays distinctive features shaped by travel, urbanization, and Aedes albopictus ecology. Dengue is the most frequently encountered arboviral illness nationally, with 117,892 reported cases from 2005 to 2023 and recurrent autochthonous clusters in southern provinces.^[2] Chikungunya, first imported in 2008, produced localized outbreaks, including a sizable event in Foshan, Guangdong, in mid-2025.^[3] Zika remains exclusively imported to date.^[4] In response, China’s National Health Commission released updated national plans for dengue (2024) and chikungunya (2025). These documents modernize diagnostic, therapeutic, and infection prevention practices for the domestic context and align with global norms while adding operational clarity.^[5,6]

2. Epidemiology snapshot: China in the global frame

China is best characterized as an area prone to importation with episodic local amplification where Aedes vectors are established.^[7] National surveillance documents a predictable dengue seasonality (June–November, peaking around September–October) and repeated localized outbreaks seeded by importations, and repeated localized outbreaks seeded by importations over the past two decades.^[2,8] In July 2025, Foshan’s chikungunya outbreak was confirmed by RT-PCR and supported by sequencing 190 genomes clustering within the Central African clade of the East/Central/South African (ECSA) genotype, consistent with a single introduction followed by local spread.^[3,9] Zika has remained limited to imported cases, with surveillance emphasizing risk communication to pregnant women and their providers, and laboratory readiness for rapid confirmation.^[4,10,11] These patterns explain why the plans were revised and why rapid dengue–chikungunya differential testing has been mandated not only at referral hospitals but also at county and township levels of care.

3. Epidemiologic and operational rationale for updating national arboviral plans

The impetus for issuing the updated national plans arose from three interrelated considerations:

• Epidemiologic transition – a shift toward mixed patterns of arboviral transmission.

• Clinical risk mitigation – the need to avert iatrogenic harm during the diagnostic overlap phase of illness.

• System-wide standardization – ensuring consistent practices across healthcare facilities of varying capacities.

In response, the revised plans prioritize the use of RT-qPCR or other nucleic acid amplification tests during the acute phase, recommend concurrent testing for dengue and chikungunya viruses in regions with elevated dengue risk, designate acetaminophen as the first-line antipyretic while advising against aspirin and other nonsteroidal anti-inflammatory drugs until dengue infection has been excluded, and advise against the routine use of corticosteroids or intravenous immunoglobulin for chikungunya management. Furthermore, the plans provide explicit criteria for case reporting, patient discharge, and precautionary measures, thereby aligning clinical decision-making with infection prevention objectives. These provisions are congruent with the WHO’s integrated guidelines yet are specifically adapted to the structure and operational characteristics of China’s laboratory networks and clinical pathways.^[1,5,6]

4. Core revisions and clinical implications in China’s updated national plans

Building on the epidemiologic and operational rationale, the 2024–2025 national plans introduce a coherent set of revisions that recalibrate case stratification, early clinical recognition, symptomatic therapy, the role of immunomodulation, and infection prevention and discharge operations. Collectively, these measures bring domestic practice into line with international standards while addressing implementation needs in mixed-transmission settings.

4.1. Case definitions and stratification

The 2025 chikungunya plan formalizes a three-tiered framework—suspected, clinical diagnosis, and confirmed—and emphasizes rapid case reporting. This structure acknowledges the differing diagnostic windows of molecular and serologic—RT-qPCR is most sensitive in the first 5–7 days of illness, whereas IgM/IgG detection generally begins after day 4–5 and peaks in the second week—and enables the prompt institution of precautionary measures during periods of diagnostic uncertainty.^[5]

4.2. Warning signs and escalation

Both the 2024 dengue and the 2025 chikungunya national plans codify neurologic involvement, cardiac manifestations, marked hepatic enzyme elevation, and coagulopathy as warning indicators requiring intensified monitoring and, where appropriate, escalation to higher levels of care. By making these criteria explicit, the plans harmonize bedside decisions with severity-based triage paradigms widely used in international guidance.^[1,5,6] Numeric cutoffs for selected —for example, platelet counts (<100,000/µL or <50,000/µL), elevations in ALT/AST (>3–10× ULN), and PT/INR prolongation (>1.5× control)—will be specified in a future addendum to reduce interfacility variability.

4.3. Analgesia

The plans designate acetaminophen (paracetamol) as first-line therapy and advise withholding aspirin and other nonsteroidal anti-inflammatory drug (NSAIDs) until dengue infection has been excluded, thereby mitigating hemorrhagic risk in syndromically overlapping presentations. Where severe pain persists, NSAIDs may be cautiously introduced after dengue exclusion. This harm-avoidant approach is concordant with the WHO’s integrated arboviral guideline.^[1,6]

4.4. Corticosteroids and IVIG in chikungunya

Routine use of corticosteroids or intravenous immunoglobulin (IVIG) is not recommended for chikungunya management, given the absence of robust benefit signals and the potential for adverse effects in uncomplicated diseases. This position consistent with contemporary WHO and PAHO guidance.^[1,5] However, accumulating case-based evidence suggests that IVIG may have a role in rare but severe neurological complications, particularly encephalopathy or encephalitis associated with chikungunya virus infection.^[12] Narrative reviews of neurological complications also acknowledge IVIG, along with corticosteroids, as attempted rescue immunomodulatory strategies in severe cases, albeit supported only by low-certainty evidence from case reports and small series.^[13]

4.5. Infection prevention and discharge

At the operational level, hospitals are instructed to implement vector-control measures (e.g., window and door screens, bed nets, and source reduction) and to apply explicit discharge and precaution criteria that couple defervescence with time- and/or virologic-based thresholds (e.g., RT-PCR negativity or predefined illness-day criteria). Where nucleic acid test (NAAT) is unavailable, day-of-illness criteria (based on the number of days since symptom onset) combined with vector precautions may be used as a pragmatic alternative. These provisions are intended to reduce onward mosquito-borne transmission following hospitalization and to coordinate clinical disposition with public-health objectives.^[5,6]

5. Alignment and divergence: A comparative analysis of China’s updated arboviral plans and WHO/PAHO clinical recommendations

5.1. Convergence in core clinical and operational principles

Across frameworks—China’s national plans, WHO’s integrated guidelines, and PAHO’s regional recommendations—conservative analgesia, early recognition via structured warning signs, and a focus on supportive care form the common core. China’s 2024–2025 plans closely follow the WHO’s integrated guideline and PAHO’s regional advice on these essential^[1,14].

5.2. Nuanced differences and added operational details

China’s documents add granular steps suited to cocirculation: an explicit cue for dual testing in febrile arthralgia within dengue-risk areas to minimize iatrogenic harm, and prescriptive discharge and precaution language linking clinical recovery with virologic or time thresholds—features that go beyond the higher-level principles in WHO and PAHO texts.^[1,5,6,14] A comparative synthesis of key diagnostic and treatment recommendations from China’s updated dengue and chikungunya guidance and the WHO/PAHO guidelines is summarized in Table 1.

Table 1.

China versus WHO/PAHO—selected recommendations across five domains

Domain	China (Dengue 2024; Chikungunya 2025)	WHO/PAHO
Analgesia/NSAIDs/Aspirin	Acetaminophen first-line; avoid aspirin/NSAIDs until dengue is excluded to reduce bleeding risk.	Same conservative stance in WHO/PAHO.
Corticosteroid/IVIG (Chikungunya)	Not recommended for routine care; reserve only for other indications under specialty oversight.	Not routinely recommended.
Warning signs & triage/escalation	Neurologic, cardiac, hepatic, coagulation cues with explicit escalation thresholds.	Severity-based triage using structured warning signs.
Infection-prevention & discharge	Precaution/discharge criteria tie defervescence to time and/or virologic thresholds; vector-control logic emphasized.	Principles aligned; virologic thresholds less prescriptive in chikungunya.
Pregnancy/Zika touchpoints	Zika treated mainly as imported; obstetric management references international norms.	Detailed pregnancy-specific Zika guidance.

NSAIDs: Non-steroidal anti-inflammatory Drugs; WHO: World Health Organization; PAHO: Pan American Health Organization; IVIG: Intravenous immunoglobulin.

6. Diagnostics and health system implementation in China

6.1. Point-of-care nonstructural protein 1 (NS1) antigen testing, sample referral, and NAAT via prefecture-level CDC networks

China employs a hub-and-spoke model combining frontline NS1 antigen screening with rapid NAAT confirmation through prefecture-level CDC laboratories. A 2024 cross-sectional survey in Guangzhou found all 22 sampled facilities capable of dengue NS1 antigen testing, with on-site PCR limited to higher-level hospitals; targeted training markedly improved screening awareness, thus supporting the plan’s emphasis on referral and education.^[15]

6.2. Turnaround time goals, training/QA, and hospital–public-health linkage

To assure analytic reliability and interoperability, the China CDC implemented a two-year multipathogen NAAT external quality assessment (EQA) covering dengue virus(DENV), zika virus(ZIKV), and chikungunya virus(CHIKV), demonstrating triplex NAAT capability and interlaboratory reproducibility. Hospitals operationalize three levers—training to standardize triage and test ordering, QA/EQA to sustain performance, and linkage to move from NS1 antigen test to definitive NAAT with same-day referral where feasible—thereby reducing misclassification in cocirculation settings and enabling bleeding-risk–aware analgesia. Table 2 presents the principal divergences between China’s updated plans and WHO/PAHO guidelines, emphasizing context-specific adaptations for domestic implementation. The plans would be further strengthened by a dedicated referral pathway for pregnant women, in line with WHO/PAHO recommendations.

Table 2.

Practical diagnostic matrix for Dengue/Chikungunya/Zika

Pathogen	Optimal window (post-onset)	Preferred tests (acute → convalescent)	Sample types (priority)	Common pitfalls	“Do-not-do” reminders
Dengue	0–5(7) d for virologic assays; ≥4–5 d for IgM	RT-qPCR/NAAT and/or NS1 early; then IgM (± paired serology)	Serum/plasma (NAAT/NS1); serum (IgM)	NS1 less sensitive in secondary infections; IgM cross-reactivity; a single negative NAAT outside window does not rule-out	Avoid aspirin/NSAIDs until dengue is excluded; don’t label “current” infection by IgG alone
Chikungunya	0–5(7) d for NAAT; ≥4–5 d for IgM	RT-qPCR/NAAT early; IgM/IgG later as indicated	Serum	Late testing may miss viremia; IgM persists; syndromic overlap with dengue	Do not use corticosteroids/IVIG routinely; confirm virologically before NSAIDs in overlap settings
Zika	0–7(14) d for NAAT (serum early; urine up to about 14 d); ≥7 d for IgM	RT-qPCR/NAAT on serum ± urine early; IgM later with confirmatory algorithms	Serum + urine	Serology cross-reactivity with dengue; negative serum NAAT after day 7 doesn’t exclude Zika if urine untested	Always co-test/consider dengue in compatible travel; align obstetric follow-up with WHO/PAHO guidance

d: days; IgG: Immunoglobulin G; IgM: Immunoglobulin M; RT-qPCR: Reverse transcription quantitative polymerase chain reaction; NAAT: Nucleic acid amplification test; NS1: Nonstructural protein 1 antigen test; NSAIDs: Non-steroidal anti-inflammatory drugs; IVIG: Intravenous immunoglobulin; WHO: World Health Organization; PAHO: Pan American Health Organization.

7. Evidence from China: What the data show

7.1. Outbreak investigations (field epidemiology and genotyping)

China’s outbreak responses consistently integrate rapid case finding with molecular attribution and have yielded actionable insights for bedside and public-health decisions. During the 2010 Guangdong chikungunya event, laboratory confirmation and phylogenetics placed isolates within the ECSA lineage (Indian Ocean clade), establishing an early template for source attribution that now informs escalation and vector-control triggers in current plans.^[16] In Zhejiang 2017, virus isolation and sequencing again implicated ECSA and traced transmission to an imported index, which reinforced the recurrent pattern of importation-seeded outbreaks in Aedes-competent settings.^[17] Most recently, the Foshan (Guangdong) 2025 chikungunya outbreak paired RT-PCR confirmation with whole-genome sequencing of 190 cases, demonstrating tight clustering within the Central African clade of ECSA. This provided operational evidence for a single introduction with local amplification, which justified intensified surveillance and control, while clinicians maintained dual testing for cocirculating arboviruses.^[9] Complementing these chikungunya investigations, dengue field–genomic work from Jiangxi 2019 documented autochthonous DENV-1 transmission with RT-PCR confirmation and phylogenetic relatedness to contemporaneous Cambodia strains, illustrating importation-seeded local spread outside historically high-incidence provinces and reinforcing the need for early laboratory differentiation embedded in the current plan.^[18] By contrast, China’s Zika experience remains importation-focused; phylogenetic analyses of 2016 imported cases showed lineage diversity concordant with contemporaneous global circulation, which supported laboratory readiness and obstetric risk communication without evidence of sustained local transmission.^[19]

7.2. Hospital cohorts: clinical profiles, supportive-care outcomes, and health-economic observations

Hospital-based studies of dengue from southern China provide direct, practice-shaping evidence for early recognition and supportive care. In the 2019 Xishuangbanna inpatient cohort, applying internationally recognized warning signs (e.g., persistent fever, mucosal bleeding, and early organ dysfunction) facilitated timely escalation and rational fluid stewardship; dynamic trajectories in platelets/coagulation and transaminases correlated with severe outcomes—evidence that reinforces the plan’s severity cues and monitoring cadence.^[20] A Fuzhou 2023 case series (251 patients) detailed a typical clinical spectrum (fever, myalgia/arthralgia, rash, and hepatic enzyme elevations) and documented NS1 antigen positivity in 97.61% of early-illness cases, while demonstrating the typical transition from viral detection (NAAT or NS1 antigen testing) to IgM serology after day 5 of illness as viremia wanes, thus providing empirical support for the plan’s windowed diagnostic strategy.^[21] Consistently, Zhang et al. reported 100% NS1 antigen test positivity (37/37) among early-phase samples during the Jiangxi outbreak in 2019 and delineated an importation-to-local transmission pattern.^[18] This is additional evidence that supports frontline NS1 antigen test combined with reflex NAAT in acute presentations and heightened vigilance in regions without a prior dengue burden. In secondary infections, NS1 antigen test sensitivity may decline (as noted in Table 2).

Evidence specific to vulnerable groups comes from Guangdong multicenter data in older adults (≥65 years): severe organ impairment was common among severe dengue cases, and COPD, anemia, hypoalbuminemia, and high fever emerged as independent risk factors, findings that validate lower thresholds for monitoring and escalation in frail patients under the national plans.^[22] Earlier Guangzhou 2014 cohorts further linked severe dengue to prolonged hospitalization and organ dysfunction, while documenting cocirculation of DENV-1/2, a background that supports today’s emphasis on structured triage and early laboratory confirmation in dengue mixed-serotype environments.^[23]

7.3. External quality assessments and assay performance (network readiness and reproducibility)

To operationalize a hub-and-spoke diagnostic model—frontline NS1 antigen test with reflex NAAT at prefecture or provincial laboratories—China CDC coordinated a two-year EQA for DENV, ZIKV, and CHIKV. The program verified analytical sensitivity and interlaboratory reproducibility, which supported routine triplex NAT in blood-service and regional public-health networks, precisely the infrastructure assumed by the new plan.^[4]

In parallel, a Guangzhou facility survey documented universal NS1 antigen test availability across 22/22 sites and showed that targeted clinician training increased screening uptake. This is evidence that training, QA/EQA, and hospital−CDC linkage are the decisive enablers of shortened time-to-diagnosis, reliable dual-pathogen differentiation, and harm-avoidant analgesia (i.e., withholding NSAIDs until dengue is excluded) in cocirculation settings.^[15]

Taken together, these domestically generated data provide the empirical substrate for China’s plans. They justify dual testing in febrile arthralgia, validate severity-based escalation and conservative analgesia, and demonstrate that a tiered laboratory network can deliver timely, quality-assured differentiation of dengue, chikungunya, and Zika at scale while remaining fully consonant with WHO/PAHO clinical principles.

8. Discussion

8.1. Strengths of the current Chinese plans

The 2024–2025 documents are clinically coherent and largely concordant with WHO/PAHO, while adding operational specificity that facilitates bedside implementation in cocirculation settings. Notable examples include an explicit dual-testing trigger for febrile arthralgia, structured warning signs linked to escalation, a harm-avoidant analgesia policy (acetaminophen first-line; defer aspirin/NSAIDs until dengue is excluded), explicit nonrecommendation of corticosteroids and IVIG for chikungunya, and discharge and precaution language that couples defervescence with time and/or virologic thresholds. These features plausibly reduce iatrogenic bleeding, encourage timely recognition of deterioration, and coordinate infection prevention steps with clinical disposition.

8.2. Limitations that constrain clinical use

Several areas remain underspecified for day-to-day practice. First, the plan offers limited direction on chronic chikungunya arthropathy (e.g., ≥12-week pain), with no algorithm for referral thresholds, pharmacologic options (disease-modifying antirheumatic drugs, DMARDs), or functional follow-up. Second, population-specific detail is sparse: pediatric parameters (fluids and monitoring thresholds) and an integrated pregnancy pathway (especially for Zika exposure) are largely deferred to international texts without locally adapted operational steps. Third, the diagnostic pathway is variably actionable across tiers of care; targets for turnaround time, minimum service standards (e.g., universal NS1 antigen test; NAAT referral within a defined time frame), management of missed testing windows, and handling of coinfections are not fully articulated. Fourth, while warning signs are listed, numeric cutoffs and time-bound actions (e.g., thresholds for liver enzymes, coagulation indices, and escalation timelines) are limited, which may lead to heterogeneity in responses. Finally, the early-phase analgesia section provides few bridging options (e.g., optimized acetaminophen dosing, topical analgesics, or short-course opioids in selected patients) for severe arthralgia before dengue is excluded, and the discharge criterion requiring RT-PCR negativity or day-of-illness thresholds may be challenging where NAAT access is delayed, warranting clearer contingencies.

In summary, the current plans provide strong clinical scaffolding and pragmatic operational elements. Focused additions—particularly for chronic chikungunya, special populations, diagnostic standards, and time-bound escalation—would further improve consistency and safety without altering alignment with international norms.

9. Conclusion

China’s 2024–2025 arboviral plans harmonize with WHO/PAHO principles while adding exportable operational detail, most notably dual testing in febrile arthralgia, along with precaution and discharge rules tied to virologic or time thresholds. Coupled with a networked laboratory system and EQA oversight, these choices offer a practical model for regions facing overlapping arboviral risks. Arboviral infections are a shared global challenge; China’s experience contributes to a collaborative international response focused on safety, speed, and system learning.

Conflicts of Interest

None.

Funding Statement

This study was supported by Shanghai Municipal Three-year Action Plan (2023–2025) for Strengthening Public Health System Construction (GWVI-11.1-13).